What is the first-line treatment for pruritic (itching) disorders?

From the Guidelines

The first-line treatment for pruritic disorders is self-care advice and emollients, followed by a short course of nonsedating antihistamine, as recommended by the British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 1.

Key Recommendations

• Patients with generalized pruritus of unknown origin (GPUO) should receive self-care advice and emollients, as stated in the guidelines 1.
• A short course of nonsedating antihistamine, such as fexofenadine 180 mg or loratadine 10 mg, may be considered for patients with GPUO, as recommended by the guidelines 1.
• Patients with GPUO should be referred to secondary care if there is diagnostic doubt, or if primary care management does not relieve symptoms, as stated in the guidelines 1.

Treatment Options

• Topical doxepin may be prescribed for patients with GPUO, with treatment limited to 8 days, 10% of body surface area, and 12 g daily, as recommended by the guidelines 1.
• Topical clobetasone butyrate or menthol may be beneficial for patients with GPUO, as stated in the guidelines 1.
• Nonsedative antihistamines, such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents, such as cetirizine 10 mg, may be considered for patients with GPUO, as recommended by the guidelines 1.

Important Considerations

• Sedative antihistamines are recommended only in the short-term or palliative setting, such as hydroxyzine, as stated in the guidelines 1.
• Patients with GPUO should consider acupuncture in combination with Chinese herbal remedies or as a second-line therapy, as recommended by the guidelines 1.

From the FDA Drug Label

Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily Purpose Anti-itch PRINCIPAL DISPLAY PANEL - 28.4 g Tube Carton TopCare health ™ MAXIMUM STRENGTH • OUR PHARMACISTS RECOMMEND • NDC 36800-099-02 Hydrocortisone 1% Cream ANTIPRURITIC (ANTI-ITCH) Intensive Healing Formula † NET WT 1 OZ (28.4 g)

The first-line treatment for pruritic (itching) disorders is hydrocortisone cream, which can be applied to the affected area not more than 3 to 4 times daily for adults and children 2 years of age and older 2. It is an antipruritic (anti-itch) medication, used for intensive healing of skin irritation, inflammation, and rashes 2, with an anti-itch purpose 2.

From the Research

Pruritic Disorder Treatment

The first-line treatment for pruritic (itching) disorders depends on the underlying cause of the condition.

• For inflammatory chronic pruritus, first-line treatment includes topical anti-inflammatory therapies such as:
  • Hydrocortisone (2.5%) 3
  • Triamcinolone (0.1%) 3
  • Tacrolimus ointment 3
• For neuropathic chronic pruritus, first-line treatment includes topical neuropathic agents such as:
  • Menthol 3
  • Pramoxine 3
  • Lidocaine 3
• For mixed etiologies of chronic pruritus, combinations of these therapies may be used 3
• In some cases, oral or injectable treatments such as dupilumab or methotrexate may be considered for patients who do not respond to topical therapies 3
• Other effective therapies for neuropathic pruritus include:
  • Gabapentin 3
  • Antidepressants such as sertraline or doxepin 3
  • Opioid receptor agonist/antagonists such as naltrexone or butorphanol 3
• Nonpharmacologic measures, such as proper skin care, and physical modalities, such as phototherapy or acupuncture, may also be helpful 4
• Topical glucocorticoids are commonly the first-line therapy in the management of atopic dermatitis (AD) and psoriasis patients, but may induce pruritus in certain conditions 5
• General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids 6